SB Combo 022 - 023 - 026 - 027 · OPT13SB22232627 HMO-POS 2013 SB Combo 022 - 023 - 026 - 027 022 -...

OPT13SB22232627

2013HMO-POS

SB Combo 022 - 023 - 026 - 027

022 - Optimum Gold Rewards Plan(HMO-POS) 023 - Optimum Platinum Plan(HMO-POS) Counties: Orange, Osceola, Seminole, Volusia.

026 - Optimum Gold Rewards Plan(HMO-POS) 027 - Optimum Platinum Plan(HMO-POS) Counties: Lake, Marion, Sumter.

201 3 Summary of Benefits H5594_SB_022_023_026_027_2013_CMS Accepted

H5594_SB_022_023_026_027_2013_CMS Accepted

Summary of Benefits

Optimum Gold Rewards Plan (HMO-POS) H5594_022 Optimum Platinum Plan (HMO-POS) H5594_023 Optimum Gold Rewards Plan (HMO-POS) H5594_026 Optimum Platinum Plan (HMO-POS) H5594_027

H5594 Florida Counties: H5594_022 Orange Osceola Seminole Volusia

H5594_023 Orange Osceola Seminole Volusia

H5594_026 Lake Marion Sumter

H5594_027 Lake Marion Sumter

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SECTION I – INTRODUCTION TO SUMMARY OF BENEFITS Thank you for your interest in Optimum Gold Rewards Plan (HMO-POS) and Optimum Platinum Plan (HMO-POS). Our plan is offered by Optimum HealthCare, Inc., a Medicare Advantage Health Maintenance Organization (HMO), with a point-of-service option (POS) that contracts with the Federal government. This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Optimum HealthCare, Inc. and ask for the “Evidence of Coverage”. YOU HAVE CHOICES IN YOUR HEALTH CARE As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Optimum Gold Rewards Plan (HMO-POS) and Optimum Platinum Plan (HMO-POS). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may join or leave a plan only at certain times. Please call Optimum HealthCare, Inc. at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. HOW CAN I COMPARE MY OPTIONS? You can compare Optimum Gold Rewards Plan (HMO-POS), Optimum Platinum Plan (HMO-POS), and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. WHERE IS OPTIMUM GOLD REWARDS PLAN (HMO-POS) AND OPTIMUM PLATINUM PLAN (HMO-POS) AVAILABLE? There is more than one plan listed in this Summary of Benefits. The service area for these plans include: Lake, Marion, Orange, Osceola, Seminole, Sumter, and Volusia Counties, FL. You must live in one of these areas to join the plan. WHO IS ELIGIBLE TO JOIN OPTIMUM GOLD REWARDS PLAN (HMO-POS) AND OPTIMUM PLATINUM PLAN (HMO-POS)? You can join Optimum Gold Rewards Plan (HMO-POS) or Optimum Platinum Plan (HMO-POS) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease are generally not eligible to enroll in Optimum Gold Rewards Plan (HMO-POS) or Optimum Platinum Plan (HMO-POS) unless they are members of our organization and have been since their dialysis began. CAN I CHOOSE MY DOCTORS? Optimum HealthCare, Inc. has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. In some cases, you may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at www.youroptimumhealthcare.com. Our customer service number is listed at the end of this introduction.

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WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN YOUR NETWORK? Generally, you are restricted to a doctor who is part of your network. However, we will cover your care from any provider for emergency or urgently needed care. Also, our point of service benefit allows you to get care from providers not in your network under certain conditions. For more information, please call the customer service number listed at the end of this introduction. WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN? Optimum HealthCare, Inc. has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at www.youroptimumhealthcare.com. Our customer service number is listed at the end of this introduction. DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS? Optimum Gold Rewards Plan (HMO-POS) and Optimum Platinum Plan (HMO-POS) cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. WHAT IS A PRESCRIPTION DRUG FORMULARY? Optimum HealthCare, Inc. uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at www.youroptimumhealthcare.com.

If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. HOW CAN I GET EXTRA HELP WITH MY PRESCRIPTION DRUG PLAN COSTS OR GET EXTRA HELP WITH OTHER MEDICARE COSTS? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: * 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week and see www.medicare.gov ‘Programs for People with Limited Income and Resources’ in the publication Medicare & You. * The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 or * Your State Medicaid Office. WHAT ARE MY PROTECTIONS IN THIS PLAN? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your

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coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of Optimum Gold Rewards Plan (HMO-POS) or Optimum Platinum Plan (HMO-POS), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of Optimum Gold Rewards Plan (HMO-POS) or Optimum Platinum Plan (HMO-POS), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us

before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Optimum HealthCare, Inc. for more details. WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B? Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Optimum HealthCare, Inc. for more details.

-- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

-- Osteoporosis Drugs: Injectable osteoporosis drugs for some women.

-- Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

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-- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

-- Injectable Drugs: Most injectable drugs administered incident to a physician’s service.

-- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage.

-- Some Oral Cancer Drugs: If the same drug is available in injectable form.

-- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.

-- Inhalation and Infusion Drugs administered through Durable Medical Equipment. WHERE CAN I FIND INFORMATION ON PLAN RATINGS? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on www.medicare.gov and select “Health and Drug Plans” then “Compare Drug and Health Plans” to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below.

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Please call Optimum HealthCare, Inc. for more information about Optimum Gold Rewards Plan (HMO-POS) or Optimum Platinum Plan (HMO-POS)

Visit us at www.YourOptimumHealthcare.com or, call us:

Customer Service Hours for October 1, 2012 through February 14, 2013: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. – 8:00 p.m. Eastern

Customer Service Hours for February 15, 2013 through September 30, 2013:

Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. – 8:00 p.m. Eastern

Current and Prospective members should call toll free (866)-245-5360 for questions related to Medicare Advantage and Part D Prescription Drug Programs. (TTY/TDD (800)-955-8771).

Current and Prospective members should call locally (352)-688-9131 for questions related to

Medicare Advantage and Part D Prescription Drug Programs. (TTY/TDD (800)-955-8771).

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.

Or, visit www.medicare.gov on the web.

This document may be available in other formats such as Braille, large print or other alternate formats.

This document may be available in a non-English language.

For additional information, call customer service at the phone number listed above.

Este documento puede estar disponible en diferentes formatos o idiomas. Para más información, puede llamar al servicio al cliente al número listado. Si Usted tiene necesidades especiales, éste documento puede estar disponible en otro formato.

If you have any questions about this plan’s benefits or costs, please contact Optimum HealthCare, Inc. for details.

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SECTION II – SUMMARY OF BENEFITS

Benefit Original Medicare Optimum Gold Rewards Plan

(HMO-POS) 022 IMPORTANT INFORMATION

1 – Premium and Other Important Information

In 2012 the monthly Part B Premium was $99.90 and may change for 2013 and the annual Part B deductible amount was $140 and may change for 2013. If a doctor or supplier does not accept assignment, their costs are often higher, which means you pay more. Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

General $0 monthly plan premium in addition to your monthly Medicare Part B premium.

Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Optimum Healthcare, Inc. will reduce your monthly Medicare Part B premium by up to $71.50.

In-Network $3,400 out-of-pocket limit for Medicare-covered services.


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Optimum Platinum Plan

(HMO-POS) 023 Optimum Gold Rewards Plan

(HMO-POS) 026 Optimum Platinum Plan

(HMO-POS) 027





Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However, some people will pay higher Part B and Part D premiums because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B and Part D premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Optimum Healthcare, Inc. will reduce your monthly Medicare Part B premium by up to $71.50.






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(HMO-POS) 022

2 – Doctor and Hospital Choice (For more information, see Emergency Care - #15 and Urgently Needed Care - #16.)

You may go to any doctor, specialist or hospital that accepts Medicare.

In-Network Referral required for network hospitals and specialists (for certain benefits).

SUMMARY OF BENEFITS INPATIENT CARE

3 – Inpatient Hospital Care (includes Substance Abuse and Rehabilitation Services)

In 2012 the amounts for each benefit period were: Days 1 – 60: $1156 deductible Days 61 – 90: $289 per day Days 91 – 150: $578 per lifetime reserve day These amounts may change for 2013. Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once. A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

In-Network Plan covers 90 days each benefit period. For Medicare-covered hospital stays:

- Days 1 – 7: $175 copay per day - Days 8 – 90: $0 copay per day

Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


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(HMO-POS) 027














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(HMO-POS) 022

4 – Inpatient Mental Health Care

In 2012 the amounts for each benefit period were: Days 1 – 60: $1156 deductible Days 61 – 90: $289 per day Days 91 – 150: $578 per lifetime reserve day These amounts may change for 2013. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

In-Network You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

For Medicare-covered hospital stays: - Days 1 – 7: $175 copay per day - Days 8 – 90: $0 copay per day

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


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(HMO-POS) 027

In-Network You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays:










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(HMO-POS) 022

5 – Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)

In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay were: Days 1 – 20: $0 per day Days 21 – 100: $144.50 per day These amounts may change for 2013. 100 days for each benefit period.

A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

General Authorization rules may apply. In-Network Plan covers up to 100 days each benefit period

No prior hospital stay is required. For Medicare-covered SNF stays:


6 – Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)

$0 copay. General Authorization rules may apply. In-Network $15 copay for each Medicare-covered home health visit


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Optimum Platinum Plan Optimum Gold Rewards Plan Optimum Platinum Plan

(HMO-POS) 023 (HMO-POS) 026 (HMO-POS) 027

General Authorization rules may apply. In-Network Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays:


General Authorization rules may apply. In-Network $0 copay for each Medicare-covered home health visit








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(HMO-POS) 022

7 – Hospice You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicare-certified hospice.

General You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.

OUTPATIENT CARE

8 – Doctor Office Visits

20% coinsurance General Authorization rules may apply. In-Network $0 copay for each Medicare-covered primary care doctor visit. $25 copay for each Medicare-covered specialist visit.

9 – Chiropractic Services

Supplemental routine care not covered 20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

General Authorization rules may apply. In-Network $20 copay for each Medicare-covered chiropractic visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor.


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(HMO-POS) 027




General Authorization rules may apply. In-Network $0 copay for each Medicare-covered primary care doctor visit. $15 copay for each Medicare-covered specialist visit.



General Authorization rules may apply. In-Network $15 copay for each Medicare-covered chiropractic visit Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor.




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(HMO-POS) 022

10 – Podiatry Services

Supplemental routine care not covered.

20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs.

General Authorization rules may apply. In-Network $25 copay for each Medicare-covered podiatry visit Medicare-covered podiatry visits are for medically-necessary foot care.

11 – Outpatient Mental Health Care

35% coinsurance for most outpatient mental health services Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible. “Partial hospitalization program” is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization.

General Authorization rules may apply. In-Network $25 copay for each Medicare-covered individual therapy visit

$25 copay for each Medicare-covered group therapy visit

$25 copay for each Medicare-covered individual therapy visit with a psychiatrist

$25 copay for each Medicare-covered group therapy visit with a psychiatrist

$110 copay for Medicare-covered partial hospitalization program services


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Optimum Platinum Plan (HMO-POS) 023

Optimum Gold Rewards Plan (HMO-POS) 026

Optimum Platinum Plan (HMO-POS) 027




















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(HMO-POS) 022

12 – Outpatient Substance Abuse Care

20% coinsurance General Authorization rules may apply. In-Network $25 to $250 copay for Medicare-covered individual substance abuse outpatient treatment visits

$25 to $250 copay for Medicare-covered group substance abuse outpatient treatment visits

13 – Outpatient Services

20% coinsurance for the doctor’s services Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible. 20% coinsurance for ambulatory surgical center facility services

General Authorization rules may apply. In-Network $25 copay for each Medicare-covered ambulatory surgical center visit $250 copay for each Medicare-covered outpatient hospital facility visit

14 – Ambulance Services (medically necessary ambulance services)

20% coinsurance General Authorization rules may apply. In-Network $100 copay for Medicare-covered ambulance benefits.


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(HMO-POS) 027

General Authorization rules may apply. In-Network $15 to $200 copay for Medicare-covered individual substance abuse outpatient treatment visits $15 to $200 copay for Medicare-covered group substance abuse outpatient treatment visits






General Authorization rules may apply. In-Network $100 copay for Medicare-covered ambulance benefits.




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(HMO-POS) 022

15 – Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.)

20% coinsurance for the doctor’s services Specified copayment for outpatient hospital facility emergency services. Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital. You don’t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited circumstances.

General $50 copay for Medicare-covered emergency room visits $25,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.

16 – Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.)

20% coinsurance, or a set copay NOT covered outside the U.S. except under limited circumstances.

General $20 copay for Medicare-covered urgently-needed-care visits


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(HMO-POS) 027




General

$20 copay for Medicare-covered urgently-needed-care visits

General


General



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(HMO-POS) 022

17 – Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy)

20% coinsurance General Authorization rules may apply. In-Network There may be limits on physical therapy, occupational therapy, and speech and language pathology visits. If so, there may be exceptions to these limits.

$25 copay for Medicare-covered Occupational Therapy visits $25 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

OUTPATIENT MEDICAL SERVICES AND SUPPLIES

18 – Durable Medical Equipment (includes wheelchairs, oxygen, etc.)

20% coinsurance General Authorization rules may apply.

In-Network 20% of the cost for Medicare-covered durable medical equipment


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(HMO-POS) 027

General Authorization rules may apply. In-Network There may be limits on physical therapy, occupational therapy, and speech and language pathology visits. If so, there may be exceptions to these limits. $15 copay for Medicare-covered Occupational Therapy visits $15 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits



General Authorization rules may apply. In-Network 20% of the cost for Medicare-covered durable medical equipment




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(HMO-POS) 022

19 – Prosthetic Devices (includes braces, artificial limbs and eyes, etc.)

20% coinsurance General Authorization rules may apply. In-Network 20% of the cost for Medicare-covered prosthetic devices

20 – Diabetes Programs and Supplies

20% coinsurance for diabetes self-management training 20% coinsurance for diabetes supplies 20% coinsurance for diabetic therapeutic shoes or inserts

General Authorization rules may apply. In-Network $0 copay for Medicare-covered Diabetes self-management training 0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies 20% of the cost for Medicare-covered Therapeutic shoes or inserts


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(HMO-POS) 027

General Authorization rules may apply. In-Network 20% of the cost for Medicare-covered prosthetic devices







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(HMO-POS) 022

21 – Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

20% coinsurance for diagnostic tests and x-rays $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol.

General Authorization rules may apply. In-Network $0 copay for Medicare-covered lab services $0 copay for Medicare-covered diagnostic procedures and tests $0 copay for Medicare-covered X-rays $25 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays)

20% of the cost for Medicare-covered therapeutic radiology services

If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $0 to $25 may apply

If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $0 to $25 may apply


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(HMO-POS) 027

General Authorization rules may apply. In-Network $0 copay for Medicare-covered lab services $0 copay for Medicare-covered diagnostic procedures and tests $0 copay for Medicare-covered X-rays $25 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays) 20% of the cost for Medicare-covered therapeutic radiology services If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $0 to $15 may apply If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $0 to $15 may apply




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Optimum Gold Rewards Plan

Benefit Original Medicare (HMO-POS) 022

22 – Cardiac and 20% coinsurance for Cardiac Rehabilitation services In-Network Pulmonary $25 to $250 copay for Medicare-covered Cardiac Rehabilitation 20% coinsurance for Pulmonary Rehabilitation services Rehabilitation Services Services

20% coinsurance for Intensive Cardiac Rehabilitation $25 to $250 copay for Medicare-covered Intensive services Cardiac Rehabilitation Services This applies to program services provided in a doctor’s $25 to $250 copay for Medicare-covered Pulmonary office. Specified cost sharing for program services Rehabilitation Services provided by hospital outpatient departments.

PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT PROGRAMS

23 – Preventive No coinsurance, copayment or deductible for the General Services, following: Authorization rules may apply. Wellness/Education - Abdominal Aortic Aneurysm Screening and other $0 copay for all preventive services covered under

- Bone Mass Measurement. Covered once every 24 Supplemental Original Medicare at zero cost sharing. months (more often if medically necessary) if you Benefit Programs Any additional preventive services approved by Medicare meet certain medical conditions. mid-year will be covered by the plan or by Original

Medicare. - Cardiovascular Screening

- Cervical and Vaginal Cancer Screening. Authorization rules may apply. Covered once every 2 years. Covered once a year for women with Medicare at high risk. In-Network

- Colorectal Cancer Screening The plan covers the following supplemental education/wellness programs: - Diabetes Screening

- Health Club Membership/Fitness Classes - Influenza Vaccine


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In-Network $15 to $200 copay for Medicare-covered Cardiac Rehabilitation Services $15 to $200 copay for Medicare-covered Intensive Cardiac Rehabilitation Services $15 to $200 copay for Medicare-covered Pulmonary Rehabilitation Services

General Authorization rules may apply. $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Authorization rules may apply. In-Network The plan covers the following supplemental education/wellness programs:

- Health Club Membership/Fitness Classes








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23 – Preventive - Hepatitis B Vaccine for people with Medicare who Services, are at risk Wellness/Education - HIV Screening. $0 copay for the HIV screening, but and other you generally pay 20% of the Medicare-approved Supplemental amount for the doctor’s visit. HIV screening is Benefit Programs covered for people with Medicare who are (continued) pregnant and people at increased risk for the

infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.

- Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39.

- Medicare Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren’t on dialysis or haven’t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease

- Personalized Prevention Plan Services (Annual Wellness Visits)

- Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.


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(HMO-POS) 027


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23 – Preventive - Prostate Cancer Screening Services, Prostate Specific Antigen (PSA) test only. Wellness/Education Covered once a year for all men with Medicare and other over age 50. Supplemental - Smoking and Tobacco Use Cessation Benefit Programs (counseling to stop smoking and tobacco use). (continued) Covered if ordered by your doctor. Includes two

counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits.

- Screening and behavioral counseling interventions in primary care to reduce alcohol misuse

- Screening for depression in adults

- Screening for sexually transmitted infections (STI) and high-intensity behavioral counseling to prevent STIs

- Intensive behavioral counseling for Cardiovascular Disease (bi-annual)

- Intensive behavioral therapy for obesity

- Welcome to Medicare Preventive Visits (initial preventive physical exam) When you join Medicare Part B, then you are eligible as follows. During the first 12 months of your new Part B coverage, you can get either a Welcome to Medicare Preventive Visits or an Annual Wellness Visit. After your first 12 months, you can get one Annual Wellness Visit every 12 months.


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(HMO-POS) 027


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24 – Kidney Disease 20% coinsurance for renal dialysis General and Conditions Authorization rules may apply.

20% coinsurance for kidney disease education services In-Network 20% of the cost for Medicare-covered renal dialysis $0 copay for Medicare-covered kidney disease education services

PRESCRIPTION DRUG BENEFITS

25 – Outpatient Most drugs are not covered under Original Medicare. You Drugs covered under Medicare Part B Prescription Drugs can add prescription drug coverage to Original Medicare General

by joining a Medicare Prescription Drug Plan, or you can 20% of the cost for Medicare Part B chemotherapy drugs get all your Medicare coverage, including prescription and other Part B drugs. drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.youroptimumhealthcare.com on the web. Different out-of-pocket costs may apply for people who

- have limited incomes,

- live in long term care facilities, or

- have access to Indian/Tribal/Urban (Indian Health Service) providers


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General General General Authorization rules may apply. Authorization rules may apply. Authorization rules may apply. In-Network In-Network In-Network 20% of the cost for Medicare-covered renal 20% of the cost for Medicare-covered renal 20% of the cost for Medicare-covered renal dialysis dialysis dialysis

$0 copay for Medicare-covered kidney disease education services



Drugs covered under Medicare Part B General



20% of the cost for Medicare Part B 20% of the cost for Medicare Part B 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. chemotherapy drugs and other Part B drugs. chemotherapy drugs and other Part B drugs.

Drugs covered under Medicare Part D General



This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.youroptimumhealthcare.com on the web.



Different out-of-pocket costs may apply for people who - have limited incomes,



- live in long term care facilities, or - have access to Indian/Tribal/Urban (Indian

Health Service) providers






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(HMO-POS) 022

25 – Outpatient Prescription Drugs (continued)

The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and a Part D plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Optimum Gold Rewards Plan (HMO-POS) for certain drugs. The plan will pay for certain over-the counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.


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(HMO-POS) 027

The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Optimum Platinum Plan (HMO-POS) for certain drugs. The plan will pay for certain over-the counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.

The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Optimum Gold Rewards Plan (HMO-POS) for certain drugs. The plan will pay for certain over-the counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.

The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Optimum Platinum Plan (HMO-POS) for certain drugs. The plan will pay for certain over-the counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.


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(HMO-POS) 022


You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and Optimum Gold Rewards Plan (HMO-POS) approves the exception, you will pay Tier 3: Non-Preferred Brand cost sharing for that drug.

In-Network $0 deductible. Supplemental drugs don’t count toward your out-of-pocket drug costs.

Initial Coverage You pay the following until total yearly drug costs reach $2,970:


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(HMO-POS) 027

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Optimum Platinum Plan (HMO-POS) approves the exception, you will pay Tier 3: Non-Preferred Brand cost sharing for that drug. In-Network $0 deductible. Supplemental drugs don’t count toward your out-of-pocket drug costs. Initial Coverage You pay the following until total yearly drug costs reach $2,970:

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Optimum Gold Rewards Plan (HMO-POS) approves the exception, you will pay Tier 3: Non-Preferred Brand cost sharing for that drug. In-Network $0 deductible. Supplemental drugs don’t count toward your out-of-pocket drug costs. Initial Coverage You pay the following until total yearly drug costs reach $2,970:

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Optimum Platinum Plan (HMO-POS) approves the exception, you will pay Tier 3: Non-Preferred Brand cost sharing for that drug. In-Network $0 deductible. Supplemental drugs don’t count toward your out-of-pocket drug costs. Initial Coverage You pay the following until total yearly drug costs reach $2,970:


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25 – Outpatient Retail Pharmacy Prescription Drugs Tier 1: Preferred Generic (continued) - $0 copay for a one-month (30-day) supply of drugs

in this tier

- $0 copay for a three-month (90-day) supply of drugs in this tier

Tier 2: Preferred Brand

- $35 copay for a one-month (30-day) supply of drugs in this tier


Tier 3: Non-Preferred Brand



Tier 4: Specialty Tier

- 33% coinsurance for a one-month (30-day) supply of drugs in this tier

- 33% coinsurance for a three-month (90-day) supply of drugs in this tier


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(HMO-POS) 027

Retail Pharmacy Retail Pharmacy Retail Pharmacy

Tier 1: Preferred Generic Tier 1: Preferred Generic Tier 1: Preferred Generic - $0 copay for a one-month (30-day)

supply of drugs in this tier - $0 copay for a one-month (30-day)


supply of drugs in this tier




Tier 2: Preferred Brand Tier 2: Preferred Brand Tier 2: Preferred Brand







Tier 3: Non-Preferred Brand Tier 3: Non-Preferred Brand Tier 3: Non-Preferred Brand








- 33% coinsurance for a one-month Tier 4: Specialty Tier


- 33% coinsurance for a one-month (30-day) supply of drugs in this tier (30-day) supply of drugs in this tier (30-day) supply of drugs in this tier

- 33% coinsurance for a three-month - 33% coinsurance for a three-month - 33% coinsurance for a three-month (90-day) supply of drugs in this tier (90-day) supply of drugs in this tier (90-day) supply of drugs in this tier


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(HMO-POS) 022


Long Term Care Pharmacy Tier 1: Preferred Generic








Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed.


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(HMO-POS) 027

Long Term Care Pharmacy Long Term Care Pharmacy Long Term Care Pharmacy Tier 1: Preferred Generic Tier 1: Preferred Generic Tier 1: Preferred Generic












Tier 4: Specialty Tier Tier 4: Specialty Tier Tier 4: Specialty Tier

- 33% coinsurance for a one-month - 33% coinsurance for a one-month - 33% coinsurance for a one-month (31-day) supply of drugs in this tier (31-day) supply of drugs in this tier (31-day) supply of drugs in this tier





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(HMO-POS) 022


Mail Order

Tier 1: Preferred Generic - $0 copay for a one-month (30-day) supply of drugs

in this tier










- 33% coinsurance for a three-month (90-day) supply of drugs in this tier


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(HMO-POS) 027

Mail Order Mail Order Mail Order

Tier 1: Preferred Generic Tier 1: Preferred Generic Tier 1: Preferred Generic - $0 copay for a one-month (30-day)
























- 33% coinsurance for a one-month (30-day) supply of drugs in this tier (30-day) supply of drugs in this tier (30-day) supply of drugs in this tier

- 33% coinsurance for a three-month - 33% coinsurance for a three-month - 33% coinsurance for a three-month (90-day) supply of drugs in this tier (90-day) supply of drugs in this tier (90-day) supply of drugs in this tier


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(HMO-POS) 022 25 – Outpatient Coverage Gap

Prescription Drugs After your total yearly drug costs reach $2,970, you (continued) receive limited coverage by the plan on certain drugs.

You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750.


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Coverage Gap After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750. Additional Coverage Gap The plan covers many formulary generics (65% - 99% of formulary generic drugs) through the coverage gap. The plan offers additional coverage in the gap for the following tiers. You pay the following: Retail Pharmacy Tier 1: Preferred Generic

- $0 copay for a one-month (30-day) supply of all drugs covered in this tier

- $0 copay for a three-month (90-day) supply of all drugs covered in this tier

Coverage Gap After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750.

Coverage Gap After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750. Additional Coverage Gap The plan covers many formulary generics (65% - 99% of formulary generic drugs) through the coverage gap. The plan offers additional coverage in the gap for the following tiers. You pay the following: Retail Pharmacy Tier 1: Preferred Generic




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(HMO-POS) 022 25 – Outpatient

Prescription Drugs (continued)

Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay the greater of:

- 5% coinsurance, or - $2.65 copay for generic (including brand drugs

treated as generic) and a $6.60 copay for all other drugs.


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Long Term Care Pharmacy

Tier 1: Preferred Generic


Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. Mail Order Tier 1: Preferred Generic




- 5% coinsurance, or - $2.65 copay for generic (including

brand drugs treated as generic) and a $6.60 copay for all other drugs.




Long Term Care Pharmacy

Tier 1: Preferred Generic


Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. Mail Order Tier 1: Preferred Generic







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(HMO-POS) 022 25 – Outpatient Out-of-Network

Prescription Drugs Plan drugs may be covered in special circumstances, for (continued) instance, illness while traveling outside of the plan’s

service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Optimum Gold Rewards Plan (HMO-POS).

Out-of-Network Initial Coverage You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,970:

Tier 1: Preferred Generic - $0 copay for a one-month (30-day) supply of

drugs in this tier

Tier 2: Preferred Brand - $35 copay for a one-month (30-day) supply of

drugs in this tier

Tier 3: Non-Preferred Brand - $69 copay for a one-month (30-day) supply of

drugs in this tier


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Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Optimum Platinum Plan (HMO-POS).


Tier 1: Preferred Generic - $0 copay for a one-month (30-day)


Tier 2: Preferred Brand - $10 copay for a one-month (30-day)


Tier 3: Non-Preferred Brand - $65 copay for a one-month (30-day)


Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Optimum Gold Rewards Plan (HMO-POS). Out-of-Network Initial Coverage You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,970:







Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Optimum Platinum Plan (HMO-POS).









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(HMO-POS) 022

25 – Outpatient Tier 4: Specialty Tier Prescription Drugs - 33% coinsurance for a one-month (30-day) supply (continued) of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.

Out-of-Network Coverage Gap You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).

You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).


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Tier 4: Specialty Tier - 33% coinsurance for a one-month

(30-day) supply of drugs in this tier You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount. Out-of-Network Coverage Gap You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).






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(HMO-POS) 022


Additional Out-of-Network Coverage Gap You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.


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Additional Out-of-Network Coverage Gap The plan covers many formulary generics (65% - 99% of formulary generic drugs) through the coverage gap. You will be reimbursed for these drugs purchased out-of-network up to the plans’ cost of the drug minus the following: Tier 1: Preferred Generic



Additional Out-of-Network Coverage Gap You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.

Additional Out-of-Network Coverage Gap The plan covers many formulary generics (65% - 99% of formulary generic drugs) through the coverage gap. You will be reimbursed for these drugs purchased out-of-network up to the plans’ cost of the drug minus the following: Tier 1: Preferred Generic




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(HMO-POS) 022

25 – Outpatient Out-of-Network Catastrophic Coverage Prescription Drugs After your yearly out-of-pocket drug costs reach $4,750, (continued) you will be reimbursed for drugs purchased out-of-

network up to the plan’s cost of the drug minus your cost share, which is the greater of:

- 5% coinsurance, or - $2.65 copay for generic (including brand drugs

treated as generic) and a $6.60 copay for all other drugs.



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Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus your cost share, which is the greater of:













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(HMO-POS) 022 OUTPATIENT MEDICAL SERVICES AND SUPPLIES

26 – Dental Services Preventive dental services (such as cleaning) not covered. In-Network $0 copay for Medicare-covered dental benefits

- $0 copay for up to 1 oral exam(s) every year

- $0 copay for up to 2 cleaning(s) every year

- $0 copay for up to 1 fluoride treatment(s) every year

- $5 to $75 copay for up to 1 dental x-ray(s)

27 – Hearing Supplemental routine hearing exams and hearing aids not In-Network Services covered. $0 copay for Medicare-covered diagnostic hearing exams

20% coinsurance for diagnostic hearing exams. $0 copay for:

- up to 1 supplemental routine hearing exam(s) every two years

$0 copay for up to 1 hearing aid fitting-evaluation(s) every two years $0 copay for up to 1 hearing aid(s) every two years $500 plan coverage limit for hearing aids every two years.


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In-Network $0 copay for Medicare-covered dental benefits





In-Network $0 copay for Medicare-covered diagnostic hearing exams

$0 copay for: - up to 1 supplemental routine hearing

exam(s) every two years

$0 copay for up to 1 hearing aid fitting-evaluation(s) every two years

$0 copay for up to 1 hearing aid(s) every two years. $500 plan coverage limit for hearing aids every two years.






















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28 – Vision Services 20% coinsurance for diagnosis and treatment of diseases In-Network and condition of the eye. - $15 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract Supplemental routine eye exams and glasses not covered. surgery. - $0 copay for Medicare-covered exams to diagnose Medicare pays for one pair of eyeglasses or contact and treat diseases and conditions of the eye. lenses after cataract surgery.

- $0 copay for up to 1 supplemental routine eye exam(s) every year Annual glaucoma screenings covered for people at risk.

- $15 copay for up to 1 pair(s) of glasses every year

- $15 copay for up to 1 pair(s) of contacts every year

$100 plan coverage limit for eye wear every year.

Plan offers additional vision benefits. Contact plan for details.

Over-the-Counter Not covered. General Items Please visit our plan website to see our list of covered

Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.


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In-Network - $10 copay for one pair of Medicare-

covered eyeglasses or contact lenses after cataract surgery.

- $0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.

- $0 copay for up to 1 supplemental routine eye exam(s) every year



$100 plan coverage limit for eye wear every year. Plan offers additional vision benefits. Contact plan for details.

General Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.


















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(HMO-POS) 022

Transportation Not covered. In-Network (Routine) $0 copay for up to 4 one-way trip(s) to plan-approved

location every year

Acupuncture Not covered. In-Network This plan does not cover Acupuncture.

Point of Service You may go to any doctor, specialist or hospital that General accepts Medicare. Authorization rules may apply.

Out-of-Network Point of Service coverage is available for the following benefits: Medicare-covered

- Physician Specialist Services $5,000 plan coverage limit every year for the following POS Benefits: Medicare-covered

- Physician Specialist Services You may need a referral for the following Point-of-service benefits: Medicare-covered

- Physician Specialist Services

30% of the cost for Medicare covered - Physician Specialist Services


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In-Network $0 copay for up to 4 one-way trip(s) to plan-approved location every year

In-Network This plan does not cover Acupuncture.

General Authorization rules may apply. Out-of-Network Point of Service coverage is available for the following benefits: Medicare-covered



















HMO-POS 2013

201 3 Summary of Benefits

SB Combo 022 - 023 - 026 - 027

022 - Optimum Gold Rewards Plan(HMO-POS) 023 - Optimum Platinum Plan(HMO-POS) Counties: Orange, Osceola, Seminole, Volusia.

026 - Optimum Gold Rewards Plan(HMO-POS) 027 - Optimum Platinum Plan(HMO-POS) Counties: Lake, Marion, Sumter.

Optimum HealthCare, Inc. P.O. BOX 151137

Tampa, FL 33684

www.youropt imumhealthcare.com

SB Combo 022 - 023 - 026 - 027 · OPT13SB22232627 HMO-POS 2013 SB Combo 022 - 023 - 026 - 027 022 -...

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